What is Menopause?
Menopause is a naturally occurring stage in a woman’s life with diverse physical and emotional upheavals. Menopause is defined as the termination of regular menses in women due to depletion of ovarian hormones either naturally or induced by surgery, chemotherapy or radiotherapy. A normal menopause is a transition period initiated by variations in duration of regular mensesprogressing to a 12 months period of amenorrhea. The way a woman perceives these positive and negative changes is influenced by personal, family and social factors. Average age of presentation of symptoms is on an average 51 years and may last for 4 to 5 years. The induction age of menopause is guided by the number of oocytes formed during the intrauterine life and their rate of depletion over the years. Menopausal symptoms are estimated to cause a 10-15% decrease in working efficiency, a 23% increase in absence from work, and an increase of 40% in health related expenditure. Symptomatic variations correspond to the rising levels of follicle stimulating hormone (FSH) and Luteinizing hormone (LH) to some extent and a corresponding decrease in Inhibin B and A.
Causes of Menopause:
The age of menopause is considered to be genetically determined. Number of ovarian follicles varies depending on the stage of life in women. At 20 weeks of gestation approximately 7 million oocytes
- are formed that reduce to 2.5 million by birth and further deteriorate to 400000 by the onset of menarche. This process is guided by the combined effect of the hypothalamus, pituitary glands, ovary, adrenal cortex and thyroid glands. Perimenopausal alterations start appearing at around 40 to 45 years with the induction of depletion in protein synthesis by the ovaries. Due toexhaustion of ovarian follicles, the ovaries are no longer able to respond to thepituitary hormones, namely follicle-stimulating hormone (FSH) and luteinizing hormone (LH), thus the production of ovarian estrogen and progesterone ceases. Consequently ovarian abnormalities lead to dysfunctional alterations causing bleeding.
- It has been proposed that there occurs a resetting and tapering of the thermoregulatory apparatus in the body in conjunction with undulations in or loss of estrogen production, causing hot flashes. Fluctuations in the levels of It is thought that decreased estrogen levelsof estradiol and follicle-stimulating hormone (FSH) bring about a corresponding reduction in the levels of serotonin and a consequent upregulation of 5-hydroxytryptamine (serotonin) receptor in the hypothalamus which alters the set pointtemperature causing hot flashes.
- Urogenital tissues are intensely vulnerable towards estrogen, and even minor variations in estrogen level during menopause can be distressing. Even after menopause the levels of estrogen are sustainably low further enfeebling the vaginal tissues causing loss of vaginal elasticity, vaginal atrophy and volume depletion, uterine prolapse and dyspareunia thus predisposing to urinary infections.
- Depletion of estrogen stores causes a corresponding decrease in synaptic density of the hippocampus associated with loss of memory, decrease production of acetylcholine and diminution in the degradation of monoamine oxidase.
- Failure of gonads acts as a triggering factor for the resorptive effects of bone causing enhanced remodeling and bone removal. Bone loss may predispose to osteoporosis characterized by weak bones. A bone loss rate of 2 to 3% per year has been reported in early menopausal women that continues over the years and may accelerate by old age.
- Estrogen deficiency has also been correlated with an increase in levels of total cholesterol, triglycerides and low density lipoproteins and a subsequent decrease in high density lipoproteins. This increases the risk of atherogenic changes.
- Premature ovarian failure is caused by hysterectomy or ovarian surgeries, radiotherapy or chemotherapy induced for treatment of breast cancer, rarely by infections such as tuberculosis, mumps, malaria, varicella and shigella, enzyme deficiencies, Down’s syndrome, Turner syndrome, Addison’s disease and hypothyroidism.
Signs & Symptoms of Menopause:
- Vasomotor symptoms such as hot flashes i.e. sensation of warmthwhich is experienced by 85% of menopausal women and in about 25% of women it persists for 5 years or more, perspiration or sweating mostly at night times
- Urogenital symptoms are experienced by approximately 27 to 60% of menopausal women, symptoms such as vaginal dryness, dyspareunia i.e. pain during sexual activity, loss of libido or sexual dysfunction, decline in fertility, urinary incontinence experienced by 30% of women, urinary frequency and urgency, uterine bleeding, burning sensation, feeling of pressure, urinary tract infections, yellow foul smelling discharge.Unlike vasomotor symptoms, vulvovaginal atrophy does not improve over time and necessitates therapeutic intervention.
- Psychological symptoms such as sleep disturbance experienced by approximately 50% of postmenopausal women, insomnia, anxiety and depression, nervousness, mood swings, cognitive disturbances, melancholia, headache, palpitations. Actigraphy studies have proposed thata premenstrual woman in her late reproductive years loses as much as 25 minutes of sleep per night. A 3 fold increased risk of depression is reported by women during perimenopause.
- Somatic symptoms such as fatigue, loss of energy, myalgia or muscle pain,arthralgia or joint pain, reduced quality of life
- Drying of the skin, formication or sensation of insect on skin
Diagnostic tests for Menopause:
- Case history: A family history of menopausal symptoms and a personal medical history are recorded as it can affect the biological and psychological reception of menopause in women.
- Follicle stimulating hormone (FSH): FSH levels can be used to diagnose menopause though it’s not a reliable test as false readings are common during perimenopause. A high FSH level correlates with a low functioning of ovaries. Normal values of FSH during follicular stage are 4-13 mcg/dl of blood. During the ovulatory phase the value increases to 5–22 mcg/dl to 2-13 mcg/dl during the luteal phase. At the time of postmenopause the levels of FSH fluctuate between 20 and 128 mcg/dl of blood. It was reported that an FSH level of more than 22.3 IU/litre increases the chances of being menopausal.
- Anti-Müllerian hormone (AMH): AMH is a protein hormone synthesized by the ovarian follicles. Evaluation of AMH levels helps to estimate the number no ovarian follicles and hence the number of eggs in a woman. A value less than 3.57 pmol/ litre increases the chances of being menopausal.
- Oestradiol(E2): It is primarily produced by the ovaries. A level less than 126.6 pmol/litre increases the chances of being menopausal. Postmenopausal women have values lower than 10pg/ml of blood.
- Inhibin A and B: Serum levels of inhibin A and B decrease with the depletion of ovarian follicles. A detectable level of inhibin A reduces the chance of being menopausal while having an undetectable level of inhibin A does not necessarily increase the chance of being menopausal. An inhibin B level of less than 0.4 nanogram/litre increases the chances of being menopausal and vice-versa.
- Thyroid-stimulating hormone (TSH): TSH levels are correlated with thyroid functioning. In hypothyroidism TSH levels are high while in hyperthyroidism the values are low. Hypothroidism is associated with premature ovarian failure. Normal levels of thyroxine ranges between 4.5 and 12 mcg/dl with 0.7 to 1.9 mg/dl of free thyroxine and 20-47% of T3 uptake. Normal TSH levels are 0.38 to 4.70 microIU/ml.
- Densitometry: Menopause increases the risk of osteoporosis hence it is advisable to assess the bone density as a precautionary measure. It can be done by taking a radiograph of the hip or spine, or an ultrasound test of the heel or hand can be done. T-score is the bone mineral density(BMD) of the woman compared with the average values for Caucasian women aged between twenty-five and thirty-five, when bone density is at its peak. Normal T score is greater than -1; while in osteopenia the value ranges between -1 and -25. In osteoporosis T score is less than or equal to –2.5.
- Endometrial biopsy: Can be done to evaluate the health of the uterine lining. Obtained tissue is examined histopathologically for any abnormality.
Stages of Menopause:
- Premenopause: It correlates with the last menstrual cycle and follows irregular periods.
- Perimenopause: It’s the intermediate period 4-6 years before menopause corresponding to the 12 months of amenorrhea; it’s the beginning of symptomatic phase and usually occurs at forty-seven to fifty-one years of age.
- Postmenopause: This begins by the last menses but is identified usually after the period of amenorrhea. During this stage the symptoms of estrogen absence disappear. It is subdivided into 3 stages:early, occurring at fifty-one to fifty-five years of age; intermediate, occurring at fifty-five to sixty-five years of age; and late, occurring over sixty-five years of age.
Treatment for Menopause:
- Hormone Replacement Therapy (HRT): Systemic estrogen therapy is the most efficient treatment option for treating the vasomotor symptoms and the associated sleep disturbance. A 0.3mg dose oral esterified and conjugated estrogens daily or a 0.025mg dose of transdermal estradiol weekly has found to be effective in most of the cases and also associated with minimal side effects. Additionally progestin therapy can to be given if a woman has not had a hysterectomy, although whena low-dose estrogen therapy is used, intermittent progestin treatment may not be an option. Hormonal therapy is advised ineither one or more of the ways such as: a continuous cyclic therapy, continuous combined therapy which incorporates fixed continuous doses of estrogen and progestin (5 to 10 mg of progestin for 10 to 14 days), long cycle therapy whereestrogen and progesterone are given for three months continuously(progestroneis given foronly 12 days).
- In cases where estrogen is contraindicated, progestin therapy can be used. Medroxyprogesterone acetate (MPA) 20 mg daily and megestrol acetate 20 mg twice daily can provide relief from the vasomotor symptoms. Clonidine -.1-0.2 mg daily or as a 0.1mg transdermal patch weekly, decreases central noradrenergic tone thus provides relief from hot flushes. Orthostatic hypotension and drowsiness are potential side effects to be considered.
- Selective serotonin reuptake inhibitors (SSRIs)such as paroxetine 12.5 and 25 mg daily or fluoxetine 20 mg daily has been found to decrease hot flushes in 62% of women but is still under study. Potential side effects are headache, nausea, and insomnia.
- Vaginal symptoms can be treated by -.5mg of estrogen cream used only 1–3 times weekly. A 25 μgestradiol vaginal tablet can also be inserted twice weekly, which is less messy and easier to use than estrogen cream.
- To reduce the risk of osteoporosis women are advised to take 1000–1500 mg of calcium and 400–800 IU of vitamin D daily either through diet or vitamin and mineral supplementation. Hormone therapy using 0.625 mg of conjugated equine estrogen 0.625 mg with 5mg of medroxyprogesterone acetate has been found to bring about a 34% reduction in cases of hip fracture. Bisphosphonates such as alendronate in a dose of 35-70 mg per week or risedronate 35 mg per week or ibandronate 150 mg a month are other options available to specifically inhibit bone resorption.Raloxifene is a selective estrogen receptor modulators (SERMs) which when used in a dose of 60 mg, acts as both estrogen agonists andantagonists thus preventing osteoporosis.
- Selective serotonin reuptake inhibitor (SSRIs) is the most commonly used antidepressants fortreatingperimenopausal depression. It takes about 4-6 weeks to act and considered quite safe and effective. Adverse effects such as serotonin syndrome, gastrointestinal effects and excessive sweating limit its use.
Complications/Risk factors associated with HRT:
- Unscheduled vaginal bleeding: It is a common side effect of HRT observed during the first 3 months of treatment and should be duly recorded.
- Venous thromboembolism: HRT tablets have a tendency to increase the risk of developing blood clots. It can be minimized by using other formulations such as patches or gels.
Am I a Good Candidate for HRT?
Most of the women experience mild to severe form of menopausal symptoms which can be physically and psychologically distressing. HRT provides symptomatic relief in these cases. HRT can be initiated immediately after the appearance of menopausal symptoms and continued till the symptoms resolve while gradually tapering the dose. It is to be used with caution and strictly after consulting your physician in cases of ovarian and breast cancer, heart and liver disease, blood clot pathologies and pregnancy.
Recovery time and aftercare:
Menopause affects a woman both physically and psychologically. Recovering from menopausal symptoms requires medical care as well as lifestyle changes. Women are advised to reduce weight if required or maintain a healthy weight along with proper dietary habits incorporating adequate amount of rich in micronutritients, multivitamins and phytoestrogens. Alcohol consumption and smoking is should be avoided. Follow healthy and regular sleep patterns. Exercise regularly and maintain cholesterol and blood pressure within normal range.
Success Rate of HRT
Research analyses have shown an improvement in longevity and reduction in morbidity in approximately 99% of postmenopausal women in US. HRT has been found to be specifically effective in relieving vasomotor symptoms associated with menopause.
Benefits of HRT:
- Improved quality of life physically, psychologically and socially.
- It is a highly effective and efficient treatment option for menopause associated hot flushes, vaginal dryness and depression.
- Provides protection from cardiovascular diseases.
- It also plays an important role in preventing and treating menopause related osteoporosis.
Why Choose MedcureIndia?
Women often become vulnerable during menopause and keeping that in mind, we at MedcureIndia provide a customized healthcare plan aptly tailored according to personal need, preference and expectations. We assist in specialist consultation and offer medical care at affordable rates. Along with medical options for relief of menopausal symptoms we also provide psychiatric or psychological guidance.
• I had undergone treatment for breast cancer. Can I still have HRT?
Women who had undergone treatment for breast cancer may develop premature surgical menopause which is associated with more significant vasomotor symptoms as compared to natural menopause. Although HRT is considered to be a contraindication in breast cancer cases, yet in some selected cases of early stage breast cancer survivors with refractory climacteric symptoms can be used after precise discussion and careful evaluation of the risk and benefits on a case to case basis. HRT should also be used with caution in cases of heart disease, liver disease and history of blood clots.
• For how long do I need to take HRT?
If HRT is indicated, it is advised to begin with the treatment promptly after you experience your first menopausal symptoms and always strictly follow the dose as directed by the physician. It is recommended to gradually taper the dose over a period of time as sudden stoppage can further exasperate the menopausal symptoms. As the menopausal symptoms resolve, which may take approximately two to five years, then HRT can be stopped gradually.
• Do I have to use contraception while I am on HRT?
As such HRT does not help in contraception, hence if you need contraception during the year following your last period if it has happened before the age of fifty and need simultaneous relief from perimenopausal symptoms, methods of contraception such as birth control pills can be continued for approximately two years.
• What are the alternatives to HRT?
Women with increased predisposition to ovarian or breast cancer or women who are unwilling to take estrogen replacement therapy can opt for Selective estrogen receptor modulators (SERM) such as Raloxifeneand Biphosphonatesfor prevention of osteoporosis. Tibolone is a synthetic steroid compound having estrogenic, progestogenicand androgenic properties with fewer side effects and is considered effective as an alternative to HRT.